PCI Outcomes Similar at Safety-Net and Non–Safety-Net Hospitals

Patients undergoing PCI at safety-net hospitals experienced similar outcomes as patients treated at non–safety-net hospitals, according to research published August 7 in JACC: Cardiovascular Interventions.

Using data from ACC's CathPCI Registry from 2009 to 2015, Tushar Acharya, MD, et al., analyzed data from 3,746,961 patients who underwent PCI at 282 safety-net hospitals and 1,134 non–safety-net hospitals. In this study, a safety-net hospital was defined as having a PCI volume of at least 10 percent for patients without insurance, based on the Agency of Healthcare Quality and Research definition. Safety-net hospitals were twice as likely to be located in the south (66 percent vs. 31 percent) and have lower annual PCI (365 vs. 538 PCI cases) and lower annual operator volume (82 vs. 100 cases).

The results showed risk-adjusted in-hospital mortality was only marginally higher in the safety-net hospitals (at four additional patients per 1,000 cases of PCI) than in non–safety-net hospitals. Patients who went to safety-net hospitals tended to be younger (63 vs. 65 years), nonwhite, had more risk factors and more often entered through the emergency department because of a heart attack (48 percent vs. 38 percent).

The study also found that both types of hospitals had similar rates of risk-adjusted bleeding (odds ratio [OR], 1.05; 95 percent confidence interval [CI], 1.00-1.12; p = 0.062) and acute kidney injury (OR, 1.01; 95 percent CI, 0.96-1.07; p = 0.051). The results of the study are limited to the events that occurred while in the hospital.

The investigators note "that since the introduction of the Affordable Care Act, the percentage of uninsured patients in the United States has steadily declined (from 16.0% in 2010 to 9.2% in early 2015)." However, "In the absence of a foreseeable scenario of universal health care, it is perhaps safe to assume that [safety-net hospitals] SNHs will continue to play a vital role in providing much needed medical care to the underprivileged." Additionally, "patients with 'less desirable' insurance may still tend to cluster at SNHs," and under-resourced, less-mobile patients "are likely to present to SNHs near their home regardless of insurance status."

In an accompanying editorial, Theodore A. Bass, MD, FACC, wrote that in addition to being vulnerable, the patients studied frequently have little or no ability to select their access to health care institutions or medical providers based on quality outcomes. He added that the study is particularly timely because of the discussion about health care legislation that has the potential to substantially affect resources for safety-net hospitals.

"This study helps shed more light on the potential issues of health care disparity in cardiovascular interventional care in the United States […] it is important to appreciate the great heterogeneity of SNH in the current health care system to better understand and best address quality of care issues." He concludes, "it may well be that, not only are PCI outcomes noninferior at SNH compared with non-SNH, the sicker, more complicated patient with more comorbidities might perhaps be better served at a SNH."

Keywords: United States, Patient Protection and Affordable Care Act, Hospital Mortality, Medically Uninsured, Odds Ratio, Comorbidity, Healthcare Disparities, Risk Factors, Research Personnel, Confidence Intervals, Safety-net Providers, Insurance Coverage, Quality of Health Care, Emergency Service, Hospital, Myocardial Infarction, Registries, Acute Kidney Injury, Health Services Accessibility

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